Saturday, May 15, 2021

"Ding dong the witch is dead!" The CDC Throws Cold Water on COVID

Time for an Update! 

Image from: Nature.com

First, I did get immunized, and I did so with the Johnson & Johnson/Janssen product. I did not die.

I did get nervous one night a few days later at 3 AM when I had a headache--"Oh no! I'm getting cavernous venous sinus thrombosis!" (What a mouthful of words to think in the wee hours!)

No, I wasn't. I probably had a headache because I wrenched my neck doing yard work earlier. But I'm human too. I can freak out. I just have so much more technical knowledge with which to both scare myself, and with which I can calm myself down. Back to sleep. Woke up at 7. No headache. I'm fine.

What's Changed for Me?

Not much. Even with the CDC's updated guidance, it'll be a few weeks before we see what happens with masking requirements, social distancing, and all the little things we didn't notice constituted "normal" until this episode. I do feel a bit privileged. As I reported in my previous blog, immunization against COVID seems like a badge of good citizenship, a shield, a fashion that's in-fashion, and I've begun to notice that people toss "It's ok. I'm vaccinated," or "I had my shots," into conversations. To reassure? To brag? I'm not certain. I've done it with my patients. It seems like a kindness, and says "There's safety here." 

Unless you're someone who wasn't that worried in the first place, or if one has a political point of view about COVID safety that supersedes such precautions. Writing in the Philadelphia Inquirer, Allison McCook says that the change in CDC's masking guidelines don't provide any answers concerning those who might un-mask even though they are unvaccinated. She shares,

I’m not only afraid — I’m angry. Because I was really looking forward to not being afraid anymore. That, to me, is what “normality” and freedom feel like. That’s why I circled May 25 on my calendar [for her second shot]— it was the day I could stop feeling afraid that I would catch or spread COVID. And now I feel like that date is meaningless. Because even when it comes, I’ll still be afraid — not for myself, but for the future of this pandemic

She then closes with this,

So I’m still going to wear a mask, even after May 25. Please don’t yell at me about it, or accuse me of fearmongering or some weird conspiracy plot. I’m just scared

A month ago, Derek Thompson wrote in The Atlantic that deep cleaning of surfaces isn't a "victimless crime"--harmless "hygiene theater" that makes us all feel safer. It actually costs us money, time,  and effort that could be better spent on measures that actually reduce risk. His main question is: Why did it take so long for the scientific establishment to get on this bus? My answer is: "theater." 

Much of managing a public pestilence is about managing the public mind. The theater is still open for shows because that's the show so many people want to see. They're scared.

It will be interesting to see what happens. Will there be a surge? Was this change too soon? On the other hand, how much more can people take? The introverts in the world may have loved the enforced cocooning, but many of us see the risk as acceptable--and perhaps necessary. After all, how can we say the vaccine will change everything when it began to appear it had changed nothing?

This was the calculated risk of a risk-averse organization, the CDC. In a time of year when people feel expansive--springtime--their numbers still seemed to indicate a reduction in case rates and fatalities. It's reasonable to attribute this to two things: a lot of people had COVID and are immune, and a lot more people got artificial immunity from the vaccines. If this is indeed the case, you kind of have to give a little ground.

Vaccine Passports

Without these, it is argued, who knows who is and who isn't immunized? That's a fair argument, but also an impractical argument: The American social character isn't disposed to a "show me your papers" way of life. And if we have learned anything from this pandemic it is that you can only enforce limitations to the extent that there's a political path to do so. The culture and economics of an America, a South Korea, a China, a France, an India have had more impact on how things have evolved in these places than anything we have done with vaccination, medicines, or bleach. 

Vaccine Avoidance

I heard from one of my patients about vaccine adverse events. It wasn't an alarming note, just meant to be interesting, and so, interested, I dug into the Vaccine Adverse Event Reporting System (VAERS) back on April 11th. The database reported on 117 million doses of all products administered as of April 5th, with 57,000 events of all kinds reported. This works out to an adverse event rate of about 0.049% or about 1 event for every 2000 doses given. I'm not talking sore arms here. These are reported events: people have to go to the trouble to submit a report, even though anyone can. So a lot of minor issues probably go unreported, but were probably already known from the original research.

"Serious" events, including hospitalizations, deaths, and other really bad stuff occurred at a rate of about 0.006% or about 1 event for every 15,000 doses administered. It was at that point that I closed the loop: As I said previously, I was waiting for enough accumulated data to determine if something really weird was going to emerge.

It didn't.

Yeah, I hear people talking about potential "long term" harms, but they generally are unable to be specific about these. As I note in an article on my website from March 2008, it's certainly possible that vaccines can cause subtle, complex harms. But as I have aged and become more experienced, I have learned that there are so many possible ways to these subtle, complex harms, including ongoing toxic stress, too much sitting, climate change, pesticides, air pollution, doom scrolling, racism, processed foods, medical marijuana, and bourbon! So many things that I have to ask: after 117 million doses, and with these risk ratios, does it really matter if I get this thing? 

True, I could have been that one-in-a-million that gets the dreaded "brain clot", buuut...I wasn't. 

Recently I lost a brother to a horrific, aggressive, Burkitt's lymphoma that likely resulted from 15 years' exposure to immune-suppressing drugs he had to take because he was a kidney-transplant patient. His experience made death from COVID seem trivial to me. I'm not trying to minimize anyone's pain if they lost a loved one to COVID. I'm simply contrasting a very public, common, and scary phenomenon (COVID), one that is beginning to fade, to a very private--and sadly ordinary--event that touched me personally and influenced how I feel about life in a time of pestilence. COVID meant we couldn't visit in groups at the end, but it was a side show compared to the main event: cancer.

While Chris' death was sudden--from start to finish it was only 6 weeks--and awful, if he hadn't gotten the transplant, he would have spent a good part of the last 15 years on dialysis...and it's very likely he would have died within 5 to 10 years--surviving longer is rare because of the risk of infection as well as just how hard it is on the body when you can only filter off the toxins a few days a week.

And so, while I'm aware of the possible weird, subtle harms that might emerge from the shot I got at Rite-Aid a couple of weeks ago, I'm inclined to ignore them. It's all about risks and benefits. I chose mine. It seemed a reasonable choice.

Choose well.

Thursday, March 25, 2021

COVID-19 Immunity and Vaccination: An Update From the Front


I've been away from the blog for a while, as it's been a very busy semester! But things have calmed down and I'm back.  

"Should I get the vaccine?"

This is the question of the moment in my practice. To some this may seem odd. Who wouldn't want it? People are "jumping the line" and engaging in all sorts of cheats to get their shots. I heard a woman interviewed on NPR recently who said she wept when she got hers, she was so relieved to have been vaccinated.

So who wouldn't want this? 

Today we're talking about "vaccine hesitancy" which is, I believe, a kinder and more accurate term than "anti-vaxxer", which has also gained popularity as description of online communities and public antagonists who ardently oppose artificial immunization. The latter are a diffuse and widespread group who believe that vaccines are bad for health, and some who argue that vaccine programs are a plot against ordinary folks, a plot by drug companies to get money, a plot by governments to sicken or control people. 

I've stated elsewhere in this blog that artificial immunization generally works as it is supposed to, that in a sense it mimics homeopathy in its approach to disease reduction, that its value is often overstated by its promoters and understated by its opponents, that it has had less effect on population health than improved sanitation and nutrition have, and that in some it can lead to enduring negative health effects, but that predicting who will suffer such effects is difficult. As I have noted elsewhere, it can confuse early homeopathic treatment, but most people seem to do ok. In the end, it is a risk-to-benefit analysis that must be calculated by the person considering immunization. 

"Ok, ok...but should I get the vaccine?"

There are two things to consider here. The first is protection from future disease, and the second is the social climate around this disease. The first feature is the easier to navigate, so let's address that now.

There's been a lot of mixed messaging around immunity from SARS-CoV-2--the "coronavirus". Of course there are many coronaviruses, and some cause the common cold, so it's likely many of you have had a "coronavirus" before. Some are more serious, and it's true that novel viruses, like SARS-CoV-2, and its cousins SARS-CoV-1 and MERS-CoV, often caused more severe disease in people because they are new. We come into this world with a set of instructions for beating most of the common germs, and even instructions for some things not so common. But these instructions vary in their detail. Once exposed to some germ or another, those instructions for generating an immune response to that germ are revised, refined. Next time we come into contact with it, we're likely to respond better and faster, and may not even get symptoms at all.

This is one reason COVID-19 has been more lethal than the flu or common cold: we didn't have the best set of instructions for developing an immune response. Nevertheless, many people who "got" COVID didn't get too sick, or they got pretty sick but got better without having to be hospitalized. A lot of people git very sick, and many died, and sometimes this was because of immune senescence (older folks' immune systems decline in effectiveness), general poor health (obesity, diabetes, heart disease, etc.), and--sometimes--bad luck. It would be silly to ignore the fact that some otherwise perfectly healthy people in good shape got "the 'rona" and just died. Some day we may discover some genetic or other peculiarity that explains this, but right now, we just have to accept that there is vulnerability across the lifespan, even if that vulnerability varies somewhat.

I must add that some germs are just more deadly for reasons other than or in addition to their novelty in people. So of them are just bad--keep that in mind as well. COVID-19 seems to be staying at around 1-2% mortality, so it's still more deadly than a cold or the flu. 

Given the facts of the case, lacking immunity to this coronavirus--whether naturally acquired (had the disease) or artificially acquired (immunized)--poses at least some risk. The vaccine rollout addresses this pretty well. Frontline health workers and older people are first in line. Viewed another way: people constantly exposed to sick people, and the folks most likely to die from COVID need to be considered most at risk and they get the shots first. There are controversies about prioritization..., but let's not get into that here. You get the basic concept.

"I had COVID. Do I still need the vaccine?"

The short answer from my perspective is: we don't know. Currently, public health authorities recommend it if you're in an eligible group. They say this is because we don't know how long natural immunity lasts. Some experts suggest natural immunity isn't as durable as artificial immunity, but the science is murky, and some experts argue that natural immunity comes with significant risks, but if you already had COVID and survived without any subsequent health problems, that safety concern is moot, and it's likely immunity will persist for a time. It's possible that natural or artificial immunity will be similarly durable, and right now we don't know what that durability is...three months? A year? Two years? 

And as the virus evolves new versions of itself, will we have protection from those? Early research suggests, yes, probably. Again, for how long? We're not sure. So for now the message from most experts is: "When your turn in line comes up, get it!" regardless of whether or not you already had COVID.

I've been reading research reports and right now there's evidence that we don't maintain antibodies for longer than three months after infection. Antibodies are chemicals our immune cells make to bind to germs and deactivate them promptly, but you have to have been exposed to the germ at least once, first. "Circulating antibodies" have been considered a medical measure of immunity to infectious diseases. For example, my students sometimes have to get them checked for things like measles or mumps, to see if they need a booster shot before entering nursing school. 

With this pandemic, there's been intense interest in memory cells. When we get an infection, B- and T-lymphocytes--types of white blood cells--"learn" the nature of the novel germ. They use this pattern recognition to develop effective, targeted responses to beat the infection. They also generate a few copies of cells that don't join the fight. Those cells just go hide out somewhere until it's over. These are memory cells. They remember the pattern so that the next time that germ shows up, they can quickly generate new antibodies and new killer cells to mop up the problem fast, sometimes without even any symptoms! 

We've known about this process for decades, but this level of interest in it is new, and happening because of the pandemic, so you can't go to Quest or LabCorp and get your memory cells tested! It's all just research at this point.

But we now know something important that we didn't really think about before: that circulating antibodies are not the only measure of immune defense. Indeed, we now have some research that suggests this response, what immunologists call the "anamnestic response", may be more important to COVID immunity than how much antibody is swimming around in your blood. The latest research suggests this may be at least 8-12 months. I include links here for the science nerds, Rodda, et al. 2021, Quast & Tarlinton 2021. This isn't comprehensive, but gives an idea.

"And soooo?"

Right now, I'm telling people that if they had COVID within the last year or so (the period of time we have at least some evidence for), and if they want to wait a while, it's probably ok to do so. Why wait? One doesn't have to, but some people are, rightfully in my view, a little cautious about a brand new drug and a brand new technology (mRNA vaccines) until a little more time goes by. That's their personal risk-to-benefit analysis.

I'm also inclined to have people get immunized if they have special vulnerabilities (age, disease) and they have not already had COVID.

A Little Bit About the Actual Products

Pfizer and Moderna make COVID vaccines with this new technology. So far it appears to be fairly safe, and something like 90 million have been immunized in the US with at least one dose of this 2-dose regimen, so it's looking pretty good--notwithstanding that a lot of people have reported to me that they got some uncomfortable symptoms (fatigue, fevers, chills) from them. This has also been widely reported in the media. So I find people setting aside a day to recover from their shots, especially the second one. I've seen some people miss a day of work for this reason. 

The Johnson & Johnson and Astra-Zeneca products use a more familiar technology that uses DNA in a harmless virus to do the same thing in one shot. I don't have as many reports to work from, but so far it seems the side effects are less bothersome. It's hard to say what's going to happen with Astra-Zeneca's product, as there have been controversies among experts about its effectiveness, so it isn't available yet in the US. However both of these "DNA-adenovirus" products seem to be very effective at preventing serious disease. Overall, the 2-shot mRNA vaccines seem a bit more effective than the DNA-adenovirus vaccines, but the latter require only one shot and may have fewer side effects. 

"Are you going to get it?"

That's a question I get a lot. People figure that if the alternative medicine homeopathic guy gets it, there must be a good reason. It's complicated, and that takes me to the social issues surrounding mass coronavirus immunization.

I believe that having been vaccinated will become a marker of sorts for whom to trust, who can come into our "bubbles", who is a "good person" and who is a "bad person." I believe the collective mental scar from this past year and over a half-million people dead will become an enduring driver of public opinion, occupational policy, medical approaches, and administrative law. I don't know if it will be permanent, but already I am hearing about companies that will require vaccination for in-person work. I'm sure my incoming class in the fall will all be required to have been immunized in order to be in the nursing program. Hospitals will be even more dictatorial about corornavirus vaccination than they have been about flu vaccination. If immunity turns out to be long lasting, those demands may fade with time, but by that time, most Americans will have been vaccinated, either by choice or because they had to in order to keep their jobs, their place in school, and so on.

I don't believe that every school and every workplace will require it. That's harder to enforce, but I predict that it will become common for many social points of contact to demand proof of immunization before a person can [fill in the blank] with "get a job", "stay in school", or "fly on a plane" as examples. 

There will be resistance to this effort for sure--this is America, where we are often contrarian by dint of our culture! But you can bet there will be change.

More interesting is that I have begun to see individuals share that they will only consort with people who have been immunized. There's a lot of fear out there, and I'm not saying it is unjustified, but fear is on a spectrum from "foolhardy disregard" to "paralyzed panic", and I wonder how many folks are at the "paralyzed panic" end of the spectrum, and thus how common shaming of the unvaccinated might become, and how it will amplify our already-agitated social state. 

Somewhere on that spectrum is "wary regard of potential hazard"--That's where a lot of people are. That's where I've been. 

I have seen a lot of shaming of people not wearing masks. Some of those unmasked folks might be in the "foolhardy disregard" category, but some of them have medical issues that make mask-wearing difficult or dangerous--yet they too are shamed, because we see a thing and we form an instant (and uninformed) opinion. I am betting the same thing will happen with coronavirus vaccination status. One can easily see that choosing to get the shot may come down to concerns other than one's health, or risk-to-benefit analysis!

So, will I get the vaccine? If I do, it'll likely be the J&J product; I prefer drug tech that's been around for a while to tech that's brand new. That's just my experience after 30 years of practice. But will I get it, you ask?

Well, let's just wait and see.
Peace

Sunday, November 22, 2020

"Pandemic Mood Disorder" and Other Updates in Coronavirus News

Is this a thing?

I think so. I just now made up this term to describe what I'm seeing in my office these days. Back in September I proposed some ideas about post-recovery syndromes from actually having COVID-19. So far I have not seen very many people with physical problems after having COVID-19. The few I have seen seem to be doing mostly ok, but it's still early, since some have yet to return for a follow up visit. 

This doesn't surprise me too much: Most folks don't think of alternative medicine to treat the sequel of a brand new disease. So stay tuned. I suspect I'll have more to say in the coming months.

What I am seeing a lot are cases of people who are ordinarily not depressed or especially anxious, suddenly displaying signs and symptoms of clinical depression and anxiety disorders. I'm seeing behavior and conduct disorders in kids who have been kept from other kids as their parents aim to protect the family from coronavirus infection. 

I have been giving remedies for these disturbance, but not in all cases. This is because sometimes a basic "psychological hygiene" approach will address the problem. Lately I've been "prescribing" play dates for kids, establishing safer bubbles of friends and neighbors for respite and interaction, and even exercise as means of relieving the indefinite sense of pointlessness and boredom that have become a part of daily life for so many.

Remedies can heal a lot of problems, or at least help heal them, but some things are a matter of the environment. No matter how many great remedies a person takes, if he continues to smoke cigarettes, there's going to be some ongoing harm that can cause or aggravate disease. I can give a smoker Bryonia for a cough, but the cough will only improve a bit if the patient keeps engaging in the behavior that aggravated a cough in the first place!

I can give remedies for fatigue and weight problems, but if the person never engages in exercise and good nutrition, those remedies are only going to take him so far. Environment--both exterior and interior to the person--matters. The pandemic has created an environment of what I call an "ongoing toxic exposure" for many people. It's important to find ways to address our usual human needs. These don't change. We can be creative about how to address them, but that creativity can only go so far when we consider how human beings are wired and constructed.

For example, no number of Zoom play-dates will substitute for the need children have to physically and freely interact with their peers. Development just won't be the same if contact with other kids their own age is 2-dimenstional and structured through remote electronic contact. We end up with a choice: Am I more worried about a virus? Or the long term effects on my child's development of prolonged and indefinite lockdown?

I don't have a ready answer for that. Parents and people facing adult isolation have to navigate this for themselves. I can give developmental and psychiatric advice, but I can't resolve people's personal feelings, anxieties, and hopes with their moral or ethical mindsets. But I can at least specify the terms of the problem. We've been very focused on control of viral spread, but that is not the only thing at issue, and I thought that today I would share what I am seeing as a way to make the matter of choosing more understandable.

"Are you getting the vaccine?"

Homeopaths are kind of famous for rejecting immunization, and many view vaccines as a definite hazard to a person's health. Those of you who know me know that I do not.

Vaccines work, mostly. In a way they are themselves "homeopathic" in a sense (or technically, "isopathic") in that you're giving something that would in its natural state--a virus, bacteria--cause the disease we're trying to prevent. The published side effect profiles are generally pretty mild and catastrophic adverse events are rare. In homeopathic medical school we were presented with the idea that sometimes contact with a vaccine may lead to subtle or major health changes not on the published lists of side effects. 

I find this plausible, and is also a statistical explanation for research that has failed to find specific diseases linked to specific vaccines, such as the lack of a statistical link between MMR vaccine and autism. In this way, even if MMR use isn't likely to lead to a higher risk of autism specifically (that we have proven), the proposal that any vaccines may lead to an increased risk any disease hasn't been studied. So we don't know.

So this leads some people to decide, "that risk, however small, isn't for me." They don't immunize. Others decide, "that risk is small enough, and the risk I feel for the actual disease the vaccine prevents is large enough, that I'm going to immunize." As we see: it's still a matter of choosing among different risks. It's no way to run a public health program, but it is a way to view one's own health, or the health of one's children one is responsible for.

I have covered the whole conversation about this in general elsewhere. Here I'll focus it on a possible coronavirus vaccine.

"Are going to get the vaccine?" My answer to this has been "I probably won't be first in line." I could be. As a health care worker, I'll certainly qualify. Why won't I be? If you go to my "Research" page on my website, you'll see I was involved with nearly three dozen drug trials in my time doing HIV medicine. One thing I learned from that and from my 30+ years in this business observing patients is that in post-marketing trials--that is, the observations we can make of people getting a product after it is licensed and in general use--is that numbers matter. Sometimes it takes a few hundred thousand uses to see weird side effects emerge. 

Ok, but that means such side effects are statistically unlikely. Good. But I kind of want to know what those rare events are before I complete my personal "risk-to-benefit" equation. Most of the time vaccines don't seem to hurt people. There are  times when the risk might be greater or lesser. As an example, a flu shot usually isn't a big deal, but I have observed that for people with systems in a delicate balance, or when they're on a new remedy for chronic conditions, it might be best to hold off on a vaccine for the moment, until their health is more stable.

It's a myth that little things are completely harmless. It is a law of Nature that anything added to a system will change that system in some way. It is also a law of Nature that you can never be sure that such a change will be trivial. Sometimes it isn't. We're all a bit different!

So will I get the vaccine? Maybe. But I think I'll sit back and observe the roll out for a while before I decide.

So in the meantime stay well, be peaceful, and do the best you can.

Happy Thanksgiving!



Monday, September 14, 2020

"I haven't felt well since..." Post-recovery Syndromes: Tales of Lyme and COVID

When a person gets an infectious illness under normal circumstances their immune system will assure a full recovery. However some diseases leave what seems like a more or less permanent mark on those who suffer from them.

Many times I have talked with patients who tell me, "I've never felt quite well since…" And this could be anything from a parasite infection to a sexually transmitted disease to Lyme or any of a host of other conditions. More often than not these people have been treated with the appropriate antibiotics or other drugs, perhaps by another medical provider. Nevertheless, they have constellations of symptoms that troubled them for months or years to come.

I have not been terribly surprised to learn that COVID-19 has caused this problem for some people recovering from it. Broadly speaking we observe two categories of this post recovery syndrome. The first is persisting symptoms after the disease itself is resolved, and the second is persisting symptoms in patients who required hospitalization, or even treatment in an intensive care unit, for very severe disease: basically, treating the side effects or after-effects of the regular medical treatment.

Lyme disease is an example of this. Many people who present to me with complaints of long-standing Lyme have been treated with antibiotics, often on more than one occasion, and sometimes they've been practically bathed in antibiotics, often administered intravenously. One common interpretation of this failure to improve after treatment is that the germ is still being harbored somewhere in the body. This is true in selected circumstances, but a number of research studies have shown that it's not generally true. Indeed the high levels of antibiotic treatment that some of these patients receive should barely leave any bacteria in the body alive, including the microbiome! That's all those good bacteria in the gut that not only help us digest our food, but also play a significant role in our overall health and well-being.

After all those antibiotics it's no wonder people feel terrible, ever afterward!

There is an interesting line of research, and I've written about this in my blog elsewhere, that suggests that a number of infectious diseases can cause derangements in immunity, and it may be these derangements that are responsible for the wide variety and persistent nature of symptoms in people who never quite get over certain infections. In Lyme disease, I and many others call this post Lyme treatment syndrome. Recently we've begun to see a similar phenomenon with COVID-19. 

How does one begin to treat something like this? Well in classical homeopathy we would approach this like we would approach any case: interview the patient, examine him, and tried to determine which homeopathic remedy would cause this particular set of symptoms in a healthy test subject. "Like cures like." I have written elsewhere about the homeopathic treatment of COVID-19 during the acute illness, and noted that because of the potency of this infectious agent, most people will be treatable with one of a handful of remedies. However in post treatment syndromes or post recovery syndromes we universally find that the individual experience of these events leads us to great individuality in remedy selection.

So while treating an acute case of coronavirus might involve Sulfur, or Gelsemium, or Eupatorium, or one of a few other remedies, treating a chronic post recovery case could lead us to almost any remedy. This is also true in Lyme disease, and in any of a number of other infectious events such as food poisoning, pneumonia, STDs, and others. It usually is not true of the flu, or the common cold. The thing that ties these together is that post recovery syndrome is often the result of something that can have severe consequences, cause lasting inflammation, and is often in need of treatment from antibiotics or other drugs.

And they tend to be diseases that are potentially deadly.

I expect at some point I will be seeing some of these cases of people who had COVID-19 and have never been right since. In the meantime I've had the opportunity to treat some acute cases, and the nice thing about that is that people seem to recover without any further problem. The key is reaching people early in the course of the disease.

But in the event I don't see them when they're early in the course of things, I'm glad I have a tool that I can use to help them when the troubles just won't go away.

Be well!


Sunday, July 26, 2020

The "Epidemiologic Triangle" and Coronavirus




The epidemiologic triangle is a teaching device to help students think about the elements of infectious disease. The triangle on the left below, is the basic requirement for an epidemic. The one on the right is an example of how changing one part of the triangle can change the course of a potential epidemic and make it less likely, or at least less harmful to the populace.
COVID-19 Coronavirus - Flattening the Curve | Disease Triangle
This image is from Popular Mechanics, a science magazine online, and in it they discuss how the use of masks, physical distancing, isolation, disinfection--all things we've been asked to do--can create a less hospitable environment for the novel coronavirus, and thus "flatten the curve." That is, reduce the number of infections enough so that things don't climb off the charts and overwhelm our medical services.

Our new friend. Artwork: Billboard.com
This is Epidemiology 101. How strong is the germ? What's it do, and whom does it do it to? What sort of environment can it do that in? This model can be abstractly applied to various other health issues, such as tobacco smoking, obesity, and so forth, but here I'm going to limit its use to our new friend The Novel Coronavirus. 
In an article on Fivethirtyeight.com, Maggie Koerth discusses how "Every Decision Is A Risk. Every Risk Is A Decision." As we now emerge from our homes, we're trying to the calculate risk of everyday activities. Koerth details how much is controversial in risk estimation, and how we're learning from the science that is still evolving. But there are things we can estimate generally. I include the link for my readers to check out, because she also writes well about how individuals engage in such calculations.

For example, being at a gathering, outdoors, with maybe eight people you know well, and it's a sunny day...even if no one's wearing a mask, the risk is probably much lower than, say, going to a bar where you're shoulder to shoulder with any number of friends and strangers. 

That's pretty straightforward, and it's intuitive. For some people, though, both prospects are equally "terrifying." What should be an easily guessed risk-difference actually has no difference to some people. Everything is equally (and possibly, maximally) risky. This is important, because as a society our own personal psychology becomes averaged into a kind of public mood. Individual estimates--whether scientifically valid or not--all go into our collective social estimation of risk, and that in turn further adjusts how we end up behaving socially. Each of us feeds that mood, and in turn the mood feeds back onto our behavior, which in turn feeds that mood and so on.

But it's not a cycle, more like a spiral. The process keeps changing with millions of individual adjustments that then alter the next moment in the cycle. This leads me to what was for me the most validating thing about Koerth's article: we're adapting. There may be a terrific vaccine around the corner. We may achieve herd immunity one day--either of these changing the host from "susceptible" to "non-susceptible." Or we may never find a decent, safe vaccine (I, for one, will not be lining up for the "first batch" of whatever soup that is--I've been personally involved in too many drug research studies!), and herd immunity may be years away.

Doesn't matter. I already see signs that people are, individually, beginning to adjust their personal risk calculus in terms that favor other things. How long can I go without visiting my elder parents? How long can my kid miss school? How long can I spin my wheels while my business withers? How long can I put off elective surgery? College? Other plans?

Eventually most of us will begin to reframe risk in broader terms that balance out other needs in our lives. This was true in the Flu Pandemic of 1918-19, and nothing about people has changed so much that this will not be the case today. It will be.

What Else Does the Triangle Tell Us?
Let me pivot to something that may give us a glimpse into this near-future: Host susceptibility. 

When I was working with HIV patients earlier in my career, it certainly looked as if that virus was really deadly. The ravages of AIDS make COVID-19 look like a wimp. Yeah, COVID kills some, but AIDS killed everybody.

Or so we thought. 

Turns out that once we had some drugs available, and we had some time to collect ourselves after losing so many bright lights (sons, daughters, Freddie Mercury, Robert Mapplethorpe, Arthur Ashe, Elizabeth Glaser...) to HIV, and after we had better technology to just understand a germ that was so much more novel than today's coronavirus, we learned that HIV was also subject to the Rule of the Triangle. HIV was not universally virulent and hosts were not universally susceptible.

It turns out that a small-ish fraction of people have genetic mutations in their immune systems that are mostly benign. These mutations may make them a little more prone to get pneumonia or the flu, but they make it really hard for HIV to get into people's immune cells. People who have both mutations (CCR5 and CXCR4) basically can't get HIV. This feature has even been turned to advantage in HIV drugs like Fuzeon. 

I began to wonder about this a few months ago. Basically the thinking has been that all humans are susceptible to COVID. This has led to the belief among many that "If I get exposed to even one viral particle I might die." This is wrong for two reasons.

First, there's dose. We don't actually know what the "dose" of virus is that can lead to a full-blown infection. This is related partly to another aspect of our triangle: virulence. Because humans (and other creatures) are equipped with protective barriers (skin, mucus, little white blood cells that live in tissues), it usually takes more than one little tiny viral particle to get infected. This is being studied, but it's early yet, so we don't have a good sense of how much or how little virus it takes to bring on disease. There are articles out there on this, but the fact is, we just really don't know yet, because there are too many factors to to make study of this easy, and because the studies themselves are very technically difficult.

Second, there's susceptibility. This is a bit easier to guess at, and with time it will become easier to know, because the same approaches we used to study HIV can give us insights into who is more, or less, susceptible to COVID.

We come into the world with trillions of T-helper cells. These cells are by dint of evolution programmed with detectors for thousands of potential infections that live on Earth. When we're exposed to one of these diseases, a subset of T-cells programmed with that pattern begins to genetically transform themselves into even better detectors for that infection that then go after the infection with a vengeance. This is why it takes 7-10 days to get over a cold: it took your T-cells that long to read the new cold virus (they change often), make genetic adjustments, and then to bring in the rest of the players that come rushing in to rid the body of the infection. 

Lymphocytes - Cell CartoonsCould it be that some of us are just better genetically equipped than others to resist cornonavirus? I found an article recently that suggested that this is the case. I include a link here because readers might find it as interesting as I did. It basically reminded me that Nature works in mysterious ways...but it still adheres to rules. In this not-yet-peer reviewed article from a research team in Sweden, we learn that maybe antibodies--whether from prior infection or a vaccine we have yet to invent--may be less important than something we're already carrying around inside us, the valiant T-cell! 

Maybe some will find this reassuring. I do. In the flurry of "information" flooding our TVs, radios, Facebook feeds, and phones, I find it comforting to know that Nature still follows rules, and if we pay attention to those rules, perhaps we'll be able to better understand and apply our own personal risk calculations with less anxiety.

As always,
Be well!